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Pharmacies, Professionalism and Homeopathy

Retail pharmacies have a sugar pill problem. Homeopathic “remedies” look like conventional medicine when they’re stocked on pharmacy shelves, like the photo above. But unlike conventional medicine, homeopathic products don’t contain any “medicine” at all. They are effectively and sometimes literally sugar pills – placebos. Not surprisingly, there is convincing evidence to show that homeopathy is useless as a medical treatment, and fundamentally incompatible with a scientific understanding of medicine, biochemistry and even physics. Questions have been raised worldwide about the ethics of pharmacists and pharmacies selling homeopathy to consumers who may not realize what they’re buying. This practice, which appears to be growing, is attracting sharp criticism from other health professions. So why do pharmacies sell them? And will the pharmacy profession change?

Homeopathy is not herbalism

To understand why homeopathy has no place in a pharmacy, it’s essential to understand how homeopathy differs from other forms of complementary and alternative medicine (CAM). Homeopathy is often misunderstood as a natural remedy, akin to a type of herbalism. The marketing and labeling of these “remedies” encourages this perception, often describing homeopathy as a “gentle” and “natural” system of healing, and putting cryptic terms like “30C” beside long Latin names of what appears to be the active ingredients. In reality, there is little likelihood that a homeopathic remedy contains even a single molecule of any listed ingredient. So while there may be hundreds of homeopathic remedies in a pharmacy, they are chemically indistinguishable, usually containing just sugar and water. The result is a growing assortment of placebos on store shelves, alongside medicines and even supplements that actually contain active ingredients. Homeopathy was “invented” in 1796 by Samuel Hahnemann, a German physician. He described the practice as guided by two key principles, which he called “laws”:

The “Law” of Infinitesimals – Hahnemann believed that the effectiveness of a remedy increases the more that remedy was diluted. He advocated a series of sequential dilutions with shaking (succussion) after each dilution, believing that the water would “remember” its contact with the original substance. According to Hahnemann’s theories, when sufficient water has been added to dilute the original substance away so that zero molecules remain, the “remedy” was thought to be at its most powerful. Imagine putting one drop of a substance into a container of water. Only that container is 131 light-years in diameter. That’s equivalent to the “30C” dilution that is popular with homeopaths. You’d have to eat a tablet of sugar the size of the Earth to get a single molecule of the original substance.

Based on the assessment of the evidence of effectiveness of homeopathy, NHMRC concludes that there are no health conditions for which there is reliable evidence that homeopathy is effective.
Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner. Those who use homeopathy should tell their health practitioner and should keep taking any prescribed treatments. The National Health and Medical Research Council expects that the Australian public will be offered treatments and therapies based on the best available evidence.

Emphasis added.

Pharmacists should know better

Pharmacists are the health professionals with specialized training in pharmacology, and an education that concentrates on drug design, delivery and understanding how to use medicines effectively and safely. If any health professional should recognize the logical and scientific leaps that homeopathy necessitates, it should be pharmacists. Regrettably, there seems to be relatively few pharmacies that have made the deliberate decision not to sell homeopathic remedies. So that’s why it’s so heartening to see this recent commentary, from Australian pharmacist Ian Carr, who will not sell homeopathy in his pharmacy:

Fellow pharmacists, it is time to rid our shelves of these shonky products. Every time a consumer is able to pluck their chosen homeopathic drops from your shelf, you have given credence to quackery. You have increased the possibility that your patient’s next call might be to a homeopath, rather than a GP. You have helped confuse the market about what “natural” medicine might be. Perhaps your patient will decide that a homeopathic nosode will more safely protect the family from whooping cough than a real vaccine. Though no direct harm will come from imbibing from a magic bottle of pure water, there is the danger that proven treatment will be ignored, refused or delayed unnecessarily.

Poor thinking about health will lead to poor health decisions.

Many who choose a homeopathic remedy from the shelves may be totally unaware of its scientific implausibility. Your pharmacy should be ensuring patients are given clear and reasoned counselling, and in doing so, helping them avoid a lifetime of confused and deluded thinking about health.

In another column, Carr argued that staff (employee) pharmacists are just as responsible as pharmacy owners for deciding what’s on store shelves:

As an independent pharmacist proprietor, I do not stock homeopathic medicines, diet pills or ear candles. I am free to recommend therapies where I am convinced of an evidence base. However, were I an employee pharmacist in a discount chain, would I have the same opportunity to exercise my professional discretion and conscience? Or would I be encouraged to companion sell and recommend the chain’s favoured brands? Could I tell the truth and expect to keep my job?

An answer might lie in the recent newsletter from the Pharmacy Board of Australia, which warns: “Action by non-pharmacists (such as managerial staff) which impinges on the ability of pharmacists to meet their legal and ethical responsibilities may be subject to action under the Health Practitioner Regulation National Law”.

Another category of pharmacist which allows for the profusion of nonsense products is the uninvolved pharmacist, who sees no need to interfere with what goes on in the front of shop. Staff training is handed over to any company that offers it, with no oversight of quality or ethics. Given the multimillion dollar advertising by vitamin and supplement companies, the exponential growth of complementary and alternative medicines and folk cures, and the extreme level of science and health illiteracy in the populace, this laissez faire approach is not acceptable.

Pharmacists are well placed to be at the forefront of science-based medicine, trained and ready to counsel, explain and teach our clients, and help give them informed control of their health.

Another profession weighs in

The growing pressure on pharmacies to stop selling homeopathy is coming from other health professionals, too. The president of the Royal Australian College of General Practitioners (RACGP), Frank R. Jones, recently criticized pharmacies for selling homeopathy, linking the profession’s decision to sell homeopathy with the simultaneous desire to play a bigger role in the health care system:

“We would certainly encourage our pharmacy colleagues to really critically look at what they are selling at their chemists (pharmacies),” he said. “I think they are very, very conflicted and I think really if they are on board with the rest of the medical community, they have to practise evidence-based medicine.”

This follows the RACGP’s formal recommendation [PDF] that general practitioners (family doctors) stop prescribing homeopathic remedies, and that pharmacist stop stocking these products:

The RACGP supports the use of evidence-based medicine, in which current research information is used as the basis for clinical decision-making. In light of strong evidence to confirm that homeopathy has no effect beyond that of placebo as a treatment for various clinical conditions, the position of the RACGP is:

Medical practitioners should not practice homeopathy, refer patients to homeopathic practitioners, or recommend homeopathic products to their patients.

Pharmacists should not sell, recommend, or support the use of homeopathic products.

Homeopathic alternatives should not be used in place of conventional immunisation.

Private health insurers should not supply rebates for or otherwise support homeopathic services or products.

Is homeopathy’s popularity due to a distrust of modern medicines as has been recently suggested by the Chief Medical Officer for England who has just called for an independent review of the safety and efficacy of medicines? Or it is that patients are worried about the side effects associated with medicines, preferring what they perceive to be a safer approach; after all homeopathic preparations have not unsurprisingly no known toxic effects in over 200 years of use? Whatever the reason, as an evidence-based profession, why do we continue to sell homeopathic preparations in our pharmacies when the evidence shows that they do not work?

The public have a right to expect pharmacists and other health professionals to be open and honest about the effectiveness and limitations of treatments. Surely it is now the time for pharmacists to cast homeopathy from the shelves and focus on scientifically based treatments backed by clear clinical evidence.

Pharmacies can prioritize patients ahead of profits

There’s a precedent for pharmacies voluntarily ceasing sales of legal products. Most pharmacies worldwide have quit the tobacco habit, recognizing that selling tobacco isn’t compatible with providing health care. In the United States, CVS became the first national drug store to stop selling tobacco, as it changed its name to CVS Health with a bold plan to distinguish itself from its pharmacy competitors. In doing so it walked away from $2 billion in sales. Recently it even quit the US Chamber of Commerce over its stance on tobacco sales. The move has been well received and the action has been highlighted as a factor in continued expansion into what is now the largest health care organization in North America. Homeopathy isn’t tobacco, but its sale in pharmacies is raising the same questions about the profession’s intent. With pharmacists stating they want an expanded role in health care, will they confront the professional and ethical challenges that homeopathy presents? Simply stating that homeopathy is legally approved for sale is not sufficient justification to deceive consumers who may not know what they’re buying. This is an ethical issue for the profession.

Homeopathy is unethical

Ethical codes for the pharmacy profession will vary by region, but most of the ones that I have reviewed make it clear that patient’s interests are central to the pharmacist’s role, and that pharmacists must provide evidence-based information to support informed decision making. Selling sugar pills on pharmacy shelves alongside real medicine, without any explanation, could give patients the impression that homeopathy is effective. I’ve argued at length that the sale in pharmacies give homeopathy the perception of scientific legitimacy, and that this approach is fundamentally unethical. Selling placebos alongside medicine violates patient autonomy, reflecting a form of medical paternalism (or perhaps crass commercialism) that retail pharmacists need to eliminate if they want to be truly accepted as partners in the health care team. Homeopathy illustrates, with perhaps the most clarity, why selling unproven or ineffective treatments is incompatible with ethical practice. This statement from Mark Crislip sums it up nicely:

This is the paradox of alternative medicine; by understanding, we render the treatment ineffective. Yet by concealing medical knowledge, we return to a dangerous, medieval-like approach to healthcare. It is for this reason why alternative medicine is flawed. As tempting as it might be to embrace placebo-based treatments, the ethical standards we would have to sacrifice are infinitely more valuable.

A pharmacist’s defence of homeopathy

Harriet Hall’s Skepdoc Rule of Thumb states that when encountering a new or questionable claim, always try to find out who disagrees and why. Why do pharmacists defend homeopathy? Via Edzard Ernst, I found this interview with Christophe Merville, the “head pharmacist” at Boiron, one of the largest homeopathic manufacturers (if that’s the right term) in the world. Here are some of his arguments in support of homeopathy:

I remember attending the delivery of a woman and the contractions were very strong, and painful. She had some homeopathic medicine to take just at that time to make those contractions more regular and useful: less intense but longer and less brusque. I saw that happening within minutes, and I was thinking, “That’s very impressive.” That’s probably the time when I concluded that there is something to it. I witnessed the action of homeopathic medicines on pets also, on young children. I had enough personal anecdotes that I could say there is something more than just suggestion, or placebo, or just the simple act of being cared for. My attitude is to say, “There are enough signs to say that it’s really worth exploring more why it works, how it works, when does it work.” We are past the stage where we can say, “No, there is nothing.” It has been around for a long time and if was just mere placebo effect, it would have gone away, as so many different techniques did.

His explanation for how homeopathy works is equally muddled:

The main argument against homeopathy is that a remedy is very, very diluted, so it cannot work. My reaction to that is to examine what happens when you dilute something. The act of dilution is not very simple. Those molecules are interacting together, they are interacting with the walls of the container, they are interacting with the solvent, and this interaction does not adhere to a precise mathematical law. The skeptics say, “You divide the number of molecules by 100 each time, so after awhile, [sic] there is less than one chance to find one single molecule.” They have their math right, but they have their physics wrong.

Chemists try to use very pure substances. When you buy your reagent, you buy it at 99.999 percent pure. But you don’t have anything that’s 100 percent pure. It would take an infinite amount of energy to get rid of the last impurity. What I think we should explore is the fact that after a certain number of dilutions, the process is not very efficient at removing the last molecules. So there is always something that stays. That’s one thing. The second thing is in pharmacology for years, we were interested in the ability of large quantities of substances. But what about small ones? I always use the example of butterflies that can sense pheromones at great distances, salmon finding their way back to their native creek from far away, to sharks being able to detect blood in a huge amount of water. Biology uses very small quantities. In cells, you have communication between cells using a few molecules of a certain substance—and it works.

I don’t pretend that I’ve put A and B and C together, and I’m able to provide you with a complete explanation. But I would say those are things to explore. Already the research that exists points to possible action of homeopathic dilution on activation or deactivation of genes. I won’t go into details, but I welcome the skepticism, I think it’s very constructive. But what I don’t really like is people whose mind is set on their misconception of what exactly a dilution is. Of course homeopathy doesn’t violate the laws of physics and chemistry, because that’s absurd.

Even the head pharmacist at Boiron admits he cannot explain how homeopathy can work. These are just excerpts of an extended interview and I encourage you to read the entire text to appreciate the arguments that Merville is making. To his credit, Merville is clear that homeopathy doesn’t replace medicine like vaccines, nor can it cure cancer or diabetes. However his basis for concluding that homeopathy is effective seems grounded entirely in anecdotes and his own observations, neglecting to consider how easy it is to fool ourselves. The Australian review I mentioned above considered this specific argument in its review, and gave a good explanation as to why we must look at the totality of the highest quality evidence, rather than trust anecdotes or personal experiences:

It is not possible to tell whether a health treatment is effective or not simply by considering individuals’ experiences or healthcare practitioners’ beliefs. One reason personal testimonials are not reliable is that people may experience health benefits because they believe that a treatment is effective. This is known as the ‘placebo effect’. Another reason is that healthcare practitioners cannot always tell whether changes in a person’s health condition are due to the treatment or some other reason. For these reasons, medicines must be tested in a planned, structured scientific research project designed to prevent these kinds of experiences giving the false impression that a medicine is more or less effective than it really is.

Even where researchers take care to design studies in a way that minimises bias, there is a chance that the results will show a statistically significant difference in favour of a treatment, when there is actually no effect. Therefore, the results of individual studies need to be repeated in other independent studies, to make sure the effects seen were not just due to chance. The most reliable information comes from research that combines the results of all available similar studies and analyses the results together (systematic reviews).

Freedom to choose?

As an advocate for removing homeopathy from pharmacies, I’ve been accused by homeopathy advocates (both pharmacist and non-pharmacist) of wanting to limit “freedom of choice”, either the freedom to sell a legally approved product, or the freedom to buy legally approved products from pharmacy retailers. The case for not selling homeopathy in pharmacies seems pretty clear: pharmacists need to put patient interests above the desire to sell inert products that look like medicine and may confuse patients. Ending pharmacy sales does not ban homeopathy, nor will it stop the sale of homeopathy in the market. Nor is it meant to. This is simply a call for pharmacies to cease selling the products. Homeopathic “remedies”, as long as they’re legally permitted for sale, can be sold elsewhere, just like tobacco remains for sale outside pharmacies. Pulling these products out of pharmacies will signal to patients and other health professionals that (1) Homeopathy has no medicinal value (2) Pharmacies and pharmacists see homeopathy as incompatible with science-based, patient-centred, evidence-based health care.

Putting patients first

Community or retail pharmacy is a unique mix of health care delivery within a private, for-profit retailer. Yet pharmacies have a specific, designated role in the health care system. For that reason, pharmacies can and should to do more than what we might expect from another retailer. The comic XKCD said it best in a comic on “alternative literature” that is captioned with a quote about today’s pharmacy practice:

I just noticed CVS has started stocking homeopathic pills on the same shelves with–and labeled similarly to–their actual medicine. Telling someone who trusts you that you’re giving them medicine, when you know you’re not, because you want their money, isn’t just lying–it’s like an example you’d make up if you had to illustrate for a child why lying is wrong.

Pharmacists ought to know better, and they ought to do better. It’s time for the profession to act in the interests of patients. Homeopathy has no place in today’s pharmacy practice.
This is a cross-post from Science-Based Medicine. Comments are open there, and at SBP’s Facebook page.

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One thought on “Pharmacies, Professionalism and Homeopathy”

Some good suggestions for pharmacists here (though I’m skeptical of Carr’s suggestion that either the PBA or the Health Practitioner Regulation National Law will protect the job of an employee who refuses to sell her employer’s stock) but what can the rest of us do?

I for one avoid giving my business to pharmacies that prominently promote shonky products, but unfortunately that hugely reduces my options. Even the ones that don’t flog homeopathy, iridology, etc have shelves full of diet products, supplements, arthritis treatments, etc that have never been shown to be effective despite numerous studies. If you add the allopathic medicines with very poor evidence base and risk benefit ratios (e.g. SSRI antidepressants) you’re left with no options whatsoever for ethical consumer choice.

When it comes to homeopathy, yep I’m repulsed by it’s bogus claims and shonky science, but even taking into account the extra harms that can arise from implicitly endorsing it I think having a promotional scheme designed to sell large quantities of diphenoxylate (“Buy five or more packs and get a free carry bag” says the sign at my nearest pharmacy) is likely to be more harmful to customers and should be subject to greater condemnation. And that’s because diphenoxylate is more than just a placebo.